Night Eating Syndrome Questionnaire — GILLIAN YOUNG Barkalow

Nickname or Name you would like to be called by

“She/her”, “they/them”, “he/him”, “multiple” or “other”

Email

Age/Height/Weight

Expectations of our coaching together

Are you on any medication? Do you have any allergies or physical limitations?

Current and past health and physical conditions

My History With Night Eating (be detailed )

Describe your sleep. How often do you wake and for how long? How restful is your sleep when you are sleeping?

How is your emotional wellbeing?

What is your dieting history like?

What is your relationship with food and your body like?

Have you worked with an eating disorder specialist before?

What does a day in your life look like? What would you love a day in your life to look like?

Do you usually eat meals alone or with family or friends?

Current calorie and macro intake if you know:

Have you ever tracked your daily food intake? How would you be most comfortable sharing your meals with me (MyfitnessPal, food journal, photos)?

Share an average day of eating and night eating. Include times.

Where do you like to grocery shop?

Have you worked with a naturopathic doctor before?

Do you have any food allergies, intolerances or dislikes?

Have you ever tested your cortisol levels or hormones?

How would you rate your stress levels, 1-5, 1 being chill & 5 being very stressed? (Be mindful to take in emotional, physical, mental stress, cultural or social stress)

What does your morning and nighttime ritual look like?

What time and how often do you wake up and eat? What do you usually go for?

Do you have unresolved past trauma?

Are you taking any supplements?

Have you been on antibiotics? How many times?

General alcohol and caffeine intake?

Do you eat fast or slow? Do you eat sitting or on the go?

Is there anything you're not willing to give up?

Do you tend to bloat?

What are your biggest challenges with your diet? Are there any bad eating habits you're trying to break?

What are your favourite foods?

How is your emotional wellbeing?

Describe your bowel movements and regularity

If applicable, how is your menstrual cycle? Do you track it? Is it regular? Do you know how many days your cycle is? Do you experience PMS? How bad is it?

What is your current fitness routine? Share full weekly schedule in detail Monday to Sunday.

Is your day more sedentary or do you stand/walk often?

What is your NED/NES holding you back from?

How do you usually manage stress?